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Monday, July 19, 2010

Day 04 - Port Maria Health Center

Would it be redundant to say it was a beautiful morning in Jamaica? 

This was the first day that I was on my own. Steve picked me up at around 8:15AM and we set off to Port Maria Hospital.  When I arrived, there were at least 50 people waiting to be seen in the clinics. I can see that Mondays in Jamaica are no different from Mondays back home.

I met Ms. Grant as soon as I walked into the clinic (she's the "female attendant"). She remembered the Issa Trust Foundation and was very helpful in getting me set up in an office. She asked me which age groups I was comfortable seeing and I said up to 18 years. I'd later find out that this was a big mistake. But what better way to learn?

I saw THIRTY-TWO patients today. Out of my first 15 patients, 11 were school physicals for teenagers. That's when I stepped out to speak with Ms. Grant to tell her that I would no longer see anyone above 13 (as is the norm for pediatricians in Jamaica), and that I would not see school physicals. I felt that they could adequately be seen by one of the three other MDs in the clinic. She rifled through my stack of charts and removed 15 or 20 charts. But before I could breathe a sigh of relief, 5 charts came, then 5 more, etc. I think the word was getting spread that a pediatrician was in the office! Alright!

Most of the sick children I saw were presenting with fungal infections of their skin, scalp, and mouth.When I was examining one 4 year old boy whose came because of ringworm on his forearm, I saw a ring around his iris. The mother had never noticed it. This is called corneal arcus, and can be a common finding in those older than 50 years. However, in a child it can be an indicator of hypercholesterolemia. When I asked his mother she told me that her brother had died at age 27 because of heart disease. I sent this child to have his cholesterol and triglyceride levels checked. He will follow-up in two weeks, on Monday or Tuesday, so he can see one of us!

A seven-year-old girl was brought by her father who wanted to check if she had had sexual intercourse. He said she hadn't told him anything, but that he heard "talk around the village". I asked him to step outside and I spoke with the girl alone. She was speaking patois, but I could make out a few key words: "he touch me", "he say me shut up", "he lick me". I wanted to make sure I wasn't missing anything pertinent so I asked for a nurse to translate. The girl said that this event had happened "a while ago". I examined her genitalia - the tear I saw was not fresh, but was most likely less than 2 weeks old. After discussion with the head nurse I found out what I had to do: fill out a referral form to the Child Development Agency (the closest one was in Highgate), place the referral in a sealed envelope, and have the father take the little girl to the agency today for a full investigation. If the father had been a suspect, then the head nurse said she would have arranged for someone else to take the girl to the Agency. Before she left, I gave the young girl prophylactic ceftriaxone and azithromycin, and treated a ringworm that I saw during her exam.

Lessons learned:
1. Only see sick patients. School physicals can easily be completed by a non-pediatrician.
2. Review dermal bacterial and fungal infections (I found this article to be very helpful). Study the severe presentations. I saw a child who had such a diffuse infection that he was losing weight! He's coming back for a repeat visit in 2 weeks too.
3. Child protective service and child abuse service are rolled up into one: the Child Development Agency.

Note: All patient pictures were taken with the written permission of the parent accompanying the child.


  1. As I read your diary for each day I'm saddened and moved on how much of the basic pediatric equipment is unavailable. What is the reason for this - is it the cost, the lack of knowledge, the limited availablity or a combination of of reasons?

  2. I think there are two reasons. Third world governments with limited income often prioritize the health of the working-age citizen. So money is of course an important factor. Thus our first missions were dedicated to bringing in equipment and medicines. However, the second reason is even more difficult to tackle; there are far too few pediatricians in the area to act as advocates for children. Many Jamaican doctors specialize in the United States and choose to stay there. That has become our new focus: increase the advocacy for children in the area by not only providing care, but also providing education and hopefully raising a new generation of pediatricians.